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Casey SD, Zekar L, Somers MJ, Westafer LM, Reed ME, Vinson DR. Bilateral Emboli and Highest Heart Rate Predict Hospitalization of Emergency Department Patients With Acute, Low-Risk Pulmonary Embolism. Ann Emerg Med 2023; 82:369-380. [PMID: 37028997 PMCID: PMC11126867 DOI: 10.1016/j.annemergmed.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 04/09/2023]
Abstract
STUDY OBJECTIVE Some patients with acute pulmonary embolism (PE) will suffer adverse clinical outcomes despite being low risk by clinical decision rules. Emergency physician decisionmaking processes regarding which low-risk patients require hospitalization are unclear. Higher heart rate (HR) or embolic burden may increase short-term mortality risk, and we hypothesized that these variables would be associated with an increased likelihood of hospitalization for patients designated as low risk by the PE Severity Index. METHODS This was a retrospective cohort study of 461 adult emergency department (ED) patients with a PE Severity Index score of fewer than 86 points. Primary exposures were the highest observed ED HR, most proximal embolus location (proximal vs distal), and embolism laterality (bilateral vs unilateral PE). The primary outcome was hospitalization. RESULTS Of 461 patients meeting inclusion criteria, most (57.5%) were hospitalized, 2 patients (0.4%) died within 30 days, and 142 (30.8%) patients were at elevated risk by other criteria (Hestia criteria or biochemical/radiographic right ventricular dysfunction). Variablesassociated with an increased likelihood of admission were highest observed ED HR of ≥110 beats/minute (vs HR <90 beats/min) (adjusted odds ratio [aOR] 3.11; 95% confidence interval [CI] 1.07 to 9.57), highest ED HR 90 to 109 (aOR 2.03; 95% CI 1.18-3.50) and bilateral PE (aOR 1.92; 95% CI 1.13 to 3.27). Proximal embolus location was not associated with the likelihood of hospitalization (aOR 1.19; 95% CI 0.71 to 2.00). CONCLUSIONS Most patients were hospitalized, often with recognizable high-risk characteristics not accounted for by the PE Severity Index. Highest ED HR of ≥90 beats/min and bilateral PE were associated with a physician's decision for hospitalization.
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Affiliation(s)
- Scott D Casey
- Permanente Medical Group, Oakland, CA; Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network.
| | - Lara Zekar
- Department of Emergency Medicine, University of California, Davis, CA
| | - Madeline J Somers
- Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network
| | - Lauren M Westafer
- Department of Emergency Medicine, UMASS Chan Medical School-Baystate, Springfield, MA
| | - Mary E Reed
- Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network
| | - David R Vinson
- Permanente Medical Group, Oakland, CA; Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA
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2
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Ye W, Chen X, Li X, Guo X, Gu W. Oxygenation index and NT-proBNP as predictors of pulmonary hypertension and ventilation/perfusion mismatch in acute pulmonary embolism. Front Cardiovasc Med 2023; 10:1090805. [PMID: 36815020 PMCID: PMC9940751 DOI: 10.3389/fcvm.2023.1090805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 01/23/2023] [Indexed: 02/09/2023] Open
Abstract
Introduction The magnitude of pulmonary artery pressure (PAP) and the extent of ventilation/perfusion (V/Q) mismatch are essential for assessing the prognosis of acute pulmonary embolism (APE). We aimed to develop a model for predicting the status of the pulmonary circulation and arterial gas exchange functions using serum levels of cardiac biomarkers and arterial oxygenation index (OI) values. Materials and methods This single-center, retrospective observational cohort study included 224 patients with APE. Multivariate linear regression and Poisson regression were used to test the statistical association between cardiac biomarkers, OI, PAP, and V/Q mismatch. Diagnostic efficiency was calculated from a receiver operating characteristic (ROC) curve. Results Serum levels of troponin I (TNI), N-terminal pro-brain natriuretic peptide (NT-proBNP), and arterial OI magnitude significantly correlated with PAP and V/Q mismatches (P < 0.05). Multivariate linear regression showed that NT-proBNP serum levels (β = 0.002, P < 0.001) and OI values (β = -0.022, P = 0.001) significantly influenced PAP. Arterial OI (β = -0.039, P < 0.001) had a significant influence on the percentage of pulmonary vascular obstruction (PVO) as determined by perfusion scanning. Poisson regression showed that OI (odds ratio: 0.995, p < 0.001) was a predictor of the number of lung segments with V/Q mismatches. ROC area under the curve (AUC) values of NT-proBNP and OI predicting pulmonary hypertension were 0.716 and 0.730, respectively, and for V/Q mismatch scanning, the results were 0.601 and 0.634, respectively. Conclusion Arterial OI and serum levels of cardiac biomarkers may be used as indicators of pulmonary hypertension and V/Q mismatch.
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Elreichouni A, Aly S, Maciejewski K, Salem I, Ghossein N, Mankash MS, Dziura J, Mowafi H. Health services access, utilization, and barriers for Arabic-speaking refugees resettled in Connecticut, USA. BMC Health Serv Res 2022; 22:1337. [PMID: 36369007 PMCID: PMC9652044 DOI: 10.1186/s12913-022-08733-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 10/25/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Arabic-speaking refugees are the largest group of refugees arriving in the United States since 2008, yet little is known about their rates of healthcare access, utilization, and satisfaction after the end of the Refugee Medical Assistance (RMA) period. METHODS This study was a cross-sectional observational study. From January to December 2019, a household survey was conducted of newly arrived Arabic-speaking refugees in Connecticut between 2016 and 2018. Households were interviewed in Arabic either in person or over the phone by one of five researchers. Descriptive statistics were generated for information collected on demographics, prevalence of chronic conditions, patterns of health seeking behavior, insurance status and patient satisfaction using the Patient Satisfaction Questionnaire (PSQ-18). RESULTS Sixty-five households responded to the survey representing 295 Arabic-speaking refugees - of which 141 (48%) were children. Forty-seven households (72%) reported 142 chronic medical conditions among 295 individuals, 62 persons (21%) needed daily medication, 285 (97%) persons were insured. Median patient satisfaction was > 4.0 out of 5 for 6 of 7 domains of the PSQ-18 but wide variation (scores from 1.0 - 5.0). CONCLUSION Arabic-speaking refugees in Connecticut participating in this study were young. The majority remained insured after their Refugee Medical Assistance lapsed. They expressed median high satisfaction with health services but with wide variation. Inaccessibility of health services in Arabic and difficulty obtaining medications remain areas in need of improvement.
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Affiliation(s)
- Ali Elreichouni
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Sarah Aly
- Department of Emergency Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | | | - Islam Salem
- Department of Emergency Medicine, Yale University, 464 Congress Ave, Suite 260, New Haven, CT, 06519, USA
| | - Noah Ghossein
- School of Medicine, University of California-Riverside, Riverside, CA, USA
- Yale School of Public Health, Yale University, New Haven, CT, USA
| | - M Salah Mankash
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - James Dziura
- Yale Center for Analytic Sciences, Yale University, New Haven, CT, USA
- Department of Emergency Medicine, Yale University, 464 Congress Ave, Suite 260, New Haven, CT, 06519, USA
| | - Hani Mowafi
- Department of Emergency Medicine, Yale University, 464 Congress Ave, Suite 260, New Haven, CT, 06519, USA.
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4
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Yoo HH, Nunes-Nogueira VS, Fortes Villas Boas PJ, Broderick C. Outpatient versus inpatient treatment for acute pulmonary embolism. Cochrane Database Syst Rev 2022; 5:CD010019. [PMID: 35511086 PMCID: PMC9070407 DOI: 10.1002/14651858.cd010019.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is a common life-threatening cardiovascular condition, with an incidence of 23 to 69 new cases per 100,000 people each year. For selected low-risk patients with acute PE, outpatient treatment might provide several advantages over traditional inpatient treatment, such as reduction of hospitalisations, substantial cost savings, and improvements in health-related quality of life. This is an update of an earlier Cochrane Review. OBJECTIVES To assess the effects of outpatient versus inpatient treatment in low-risk patients with acute PE. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 31 May 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) of outpatient versus inpatient treatment of adults (aged 18 years and over) diagnosed with low-risk acute PE. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were short- and long-term all-cause mortality. Secondary outcomes were bleeding, adverse effects, recurrence of PE, and patient satisfaction. We used GRADE to assess certainty of evidence for each outcome. MAIN RESULTS We did not identify any new studies for this update. We included a total of two RCTs involving 453 participants. Both trials discharged participants randomised to the outpatient group within 36 hours of initial triage, and both followed participants for 90 days. One study compared the same treatment regimens in both outpatient and inpatient groups, and the other study used different treatment regimens. There was no clear difference in treatment effect for the outcomes of mortality at 30 days (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.01 to 7.98; 2 studies, 453 participants; low-certainty evidence), mortality at 90 days (RR 0.98, 95% CI 0.06 to 15.58; 2 studies, 451 participants; low-certainty evidence), major bleeding at 14 days (RR 4.91, 95% CI 0.24 to 101.57; 2 studies, 445 participants; low-certainty evidence) and at 90 days (RR 6.88, 95% CI 0.36 to 132.14; 2 studies, 445 participants; low-certainty evidence), minor bleeding (RR 1.08, 95% CI 0.07 to 16.79; 1 study, 106 participants; low-certainty evidence), recurrent PE within 90 days (RR 2.95, 95% CI 0.12 to 71.85; 2 studies, 445 participants; low-certainty evidence), and patient satisfaction (RR 0.97, 95% CI 0.90 to 1.04; 2 studies, 444 participants; moderate-certainty evidence). We downgraded the certainty of the evidence because the CIs were wide and included treatment effects in both directions, the sample sizes and numbers of events were small, and it was not possible to determine the effect of missing data or the presence of publication bias. The included studies did not assess PE-related mortality or adverse effects, such as haemodynamic instability, or adherence to treatment. AUTHORS' CONCLUSIONS Currently, only low-certainty evidence is available from two published randomised controlled trials on outpatient versus inpatient treatment in low-risk patients with acute PE. The studies did not provide evidence of any clear difference between the interventions in overall mortality, bleeding, or recurrence of PE.
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Affiliation(s)
- Hugo Hb Yoo
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University-UNESP, Botucatu, Brazil
| | - Vania Santos Nunes-Nogueira
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University-UNESP, Botucatu, Brazil
| | - Paulo J Fortes Villas Boas
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University-UNESP, Botucatu, Brazil
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Kabrhel C, Vinson DR, Mitchell AM, Rosovsky RP, Chang AM, Hernandez‐Nino J, Wolf SJ. A clinical decision framework to guide the outpatient treatment of emergency department patients diagnosed with acute pulmonary embolism or deep vein thrombosis: Results from a multidisciplinary consensus panel. J Am Coll Emerg Physicians Open 2021; 2:e12588. [PMID: 34950930 PMCID: PMC8673564 DOI: 10.1002/emp2.12588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
The outpatient treatment of select emergency department patients with acute pulmonary embolism (PE) or deep vein thrombosis (DVT) has been shown to be safe, cost effective and associated with high patient satisfaction. Despite this, outpatient PE and DVT treatment remains uncommon. To address this, the American College of Emergency Physicians assembled a multidisciplinary team of content experts to provide evidence-based recommendations and practical advice to help clinicians safely treat patients with low-risk PE and DVT without hospitalization. The emergency clinician must stratify the patient's risk of clinical decompensation due to their PE or DVT as well as their risk of bleeding due to anticoagulation. The clinician must also select and start an anticoagulant and ensure that the patient has access to the medication in a timely manner. Reliable follow-up is critical, and the patient must also be educated about signs or symptoms that should prompt a return to the emergency department. To facilitate access to these recommendations, the consensus panel also created 2 web-based "point-of-care tools."
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Affiliation(s)
- Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular EmergenciesMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - David R. Vinson
- Department of Emergency Medicine, Kaiser Permanente Division of Research and the CREST Network, Oakland, CAKaiser Permanente Roseville Medical CenterRosevilleCaliforniaUSA
| | - Alice Marina Mitchell
- Department of Emergency Medicine, Richard L. Roudebush VAMCIndiana University School of MedicineIndianapolisIndianaUSA
| | - Rachel P. Rosovsky
- Division of HematologyDepartment of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Anna Marie Chang
- Department of Emergency MedicineThomas Jefferson University HospitalsPhiladelphiaPennsylvaniaUSA
| | | | - Stephen J. Wolf
- Department of Emergency MedicineDenver Health and University of Colorado School of MedicineDenverColoradoUSA
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Nguyen PC, Stevens H, Peter K, McFadyen JD. Submassive Pulmonary Embolism: Current Perspectives and Future Directions. J Clin Med 2021; 10:jcm10153383. [PMID: 34362166 PMCID: PMC8347177 DOI: 10.3390/jcm10153383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 11/22/2022] Open
Abstract
Submassive pulmonary embolism (PE) lies on a spectrum of disease severity between standard and high-risk disease. By definition, patients with submassive PE have a worse outcome than the majority of those with standard-risk PE, who are hemodynamically stable and lack imaging or laboratory features of cardiac dysfunction. Systemic thrombolytic therapy has been proven to reduce mortality in patients with high-risk disease; however, its use in submassive PE has not demonstrated a clear benefit, with haemodynamic improvements being offset by excess bleeding. Furthermore, meta-analyses have been confusing, with conflicting results on overall survival and net gain. As such, significant interest remains in optimising thrombolysis, with recent efforts in catheter-based delivery as well as upcoming studies on reduced systemic dosing. Recently, long-term cardiorespiratory limitations following submassive PE have been described, termed post-PE syndrome. Studies on the ability of thrombolytic therapy to prevent this condition also present conflicting evidence. In this review, we aim to clarify the current evidence with respect to submassive PE management, and also to highlight shortcomings in current definitions and prognostic factors. Additionally, we discuss novel therapies currently in preclinical and early clinical trials that may improve outcomes in patients with submassive PE.
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Affiliation(s)
- Phillip C. Nguyen
- Department of Haematology, Alfred Hospital, Melbourne, VIC 3181, Australia; (P.C.N.); (H.S.)
| | - Hannah Stevens
- Department of Haematology, Alfred Hospital, Melbourne, VIC 3181, Australia; (P.C.N.); (H.S.)
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC 3004, Australia;
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC 3004, Australia;
- Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC 3800, Australia
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, VIC 3010, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC 3181, Australia
| | - James D. McFadyen
- Department of Haematology, Alfred Hospital, Melbourne, VIC 3181, Australia; (P.C.N.); (H.S.)
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC 3004, Australia;
- Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC 3800, Australia
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, VIC 3010, Australia
- Correspondence: ; Tel.: +61-3-9076-2179
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7
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Hendriks SV, Hout WBVD, van Bemmel T, Bistervels IM, Eijsvogel M, Faber LM, Hofstee HMA, van der Hulle T, Iglesias Del Sol A, Kruip MJHA, Mairuhu ATA, Middeldorp S, Nijkeuter M, Huisman MV, Klok FA. Home Treatment Compared to Initial Hospitalization in Normotensive Patients with Acute Pulmonary Embolism in the Netherlands: A Cost Analysis. Thromb Haemost 2021; 122:427-433. [PMID: 34041736 DOI: 10.1055/a-1518-1847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Venous thromboembolism constitutes substantial health care costs amounting to approximately 60 million euros per year in the Netherlands. Compared with initial hospitalization, home treatment of pulmonary embolism (PE) is associated with a cost reduction. An accurate estimation of cost savings per patient treated at home is currently lacking. AIM The aim of this study was to compare health care utilization and costs during the first 3 months after a PE diagnosis in patients who are treated at home versus those who are initially hospitalized. METHODS Patient-level data of the YEARS cohort study, including 383 normotensive patients diagnosed with PE, were used to estimate the proportion of patients treated at home, mean hospitalization duration in those who were hospitalized, and rates of PE-related readmissions and complications. To correct for baseline differences within the two groups, regression analyses was performed. The primary outcome was the average total health care costs during a 3-month follow-up period for patients initially treated at home or in hospital. RESULTS Mean hospitalization duration for the initial treatment was 0.69 days for those treated initially at home (n = 181) and 4.3 days for those initially treated in hospital (n = 202). Total average costs per hospitalized patient were €3,209 and €1,512 per patient treated at home. The adjusted mean difference was €1,483 (95% confidence interval: €1,181-1,784). CONCLUSION Home treatment of hemodynamically stable patients with acute PE was associated with an estimated net cost reduction of €1,483 per patient. This difference underlines the advantage of triage-based home treatment of these patients.
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Affiliation(s)
- Stephan V Hendriks
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Wilbert B van den Hout
- Department of Biomedical Data Science-Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas van Bemmel
- Department of Internal Medicine, Gelre Hospital, Apeldoorn, The Netherlands
| | - Ingrid M Bistervels
- Department of Internal Medicine, Flevoziekenhuis, Almere, The Netherlands.,Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Michiel Eijsvogel
- Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Laura M Faber
- Department of Internal Medicine, Rode Kruis Hospital, Beverwijk, The Netherlands
| | - Herman M A Hofstee
- Department of Internal Medicine, Haaglanden Medisch Centrum, The Hague, The Netherlands
| | - Tom van der Hulle
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mathilde Nijkeuter
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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8
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Barco S, Schmidtmann I, Ageno W, Bauersachs RM, Becattini C, Bernardi E, Beyer-Westendorf J, Bonacchini L, Brachmann J, Christ M, Czihal M, Duerschmied D, Empen K, Espinola-Klein C, Ficker JH, Fonseca C, Genth-Zotz S, Jiménez D, Harjola VP, Held M, Iogna Prat L, Lange TJ, Manolis A, Meyer A, Mustonen P, Rauch-Kroehnert U, Ruiz-Artacho P, Schellong S, Schwaiblmair M, Stahrenberg R, Westerweel PE, Wild PS, Konstantinides SV, Lankeit M. Early discharge and home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban: an international multicentre single-arm clinical trial. Eur Heart J 2021; 41:509-518. [PMID: 31120118 DOI: 10.1093/eurheartj/ehz367] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 04/27/2019] [Accepted: 05/13/2019] [Indexed: 12/30/2022] Open
Abstract
AIMS To investigate the efficacy and safety of early transition from hospital to ambulatory treatment in low-risk acute PE, using the oral factor Xa inhibitor rivaroxaban. METHODS AND RESULTS We conducted a prospective multicentre single-arm investigator initiated and academically sponsored management trial in patients with acute low-risk PE (EudraCT Identifier 2013-001657-28). Eligibility criteria included absence of (i) haemodynamic instability, (ii) right ventricular dysfunction or intracardiac thrombi, and (iii) serious comorbidities. Up to two nights of hospital stay were permitted. Rivaroxaban was given at the approved dose for PE for ≥3 months. The primary outcome was symptomatic recurrent venous thromboembolism (VTE) or PE-related death within 3 months of enrolment. An interim analysis was planned after the first 525 patients, with prespecified early termination of the study if the null hypothesis could be rejected at the level of α = 0.004 (<6 primary outcome events). From May 2014 through June 2018, consecutive patients were enrolled in seven countries. Of the 525 patients included in the interim analysis, three (0.6%; one-sided upper 99.6% confidence interval 2.1%) suffered symptomatic non-fatal VTE recurrence, a number sufficiently low to fulfil the condition for early termination of the trial. Major bleeding occurred in 6 (1.2%) of the 519 patients comprising the safety population. There were two cancer-related deaths (0.4%). CONCLUSION Early discharge and home treatment with rivaroxaban is effective and safe in carefully selected patients with acute low-risk PE. The results of the present trial support the selection of appropriate patients for ambulatory treatment of PE.
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Affiliation(s)
- Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Mainz, Obere Zahlbacher Strasse 69, 55131 Mainz, Germany
| | - Walter Ageno
- Department of Medicine and Surgery, Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
| | - Rupert M Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt, Grafenstrasse 9, 64283 Darmstadt, Germany
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Via G. Dottori 1, 06129 Perugia, Italy
| | - Enrico Bernardi
- Department of Emergency Medicine, ULSS n.7, Via Brigata Bisagno 4, 31015 Conegliano (Treviso), Italy
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division of Hematology, Department of Medicine I, University Hospital "Carl Gustav Carus", Fetscherstrasse 74, 01307 Dresden, Germany.,Kings Thrombosis Service, Department of Hematology, Kings College London, Denmark Hill, Brixton, SE5 9RS, London, UK
| | - Luca Bonacchini
- S.C. Medicina d'Urgenza e Pronto Soccorso, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore 3, 20162 Milano, Italy
| | - Johannes Brachmann
- II Medical Department, Coburg Hospital, Ketschendorfer Strasse 33, 96450 Coburg, Germany
| | - Michael Christ
- Emergency Care (Notfallzentrum), Luzerner Kantonsspital, 6000 Luzern, Switzerland
| | - Michael Czihal
- Division of Vascular Medicine, Hospital of the Ludwig-Maximilians-University, Georgenstrasse 5, 80799 Munich, Germany
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany
| | - Klaus Empen
- Department of Internal Medicine, University Medical Center, Fleischmannstrasse 6, 17489 Greifswald, Germany
| | - Christine Espinola-Klein
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany.,Center for Cardiology, Cardiology 1, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Joachim H Ficker
- Department of Respiratory Medicine, Nuremberg General Hospital/Paracelsus Medical University, Prof.-Ernst-Nathan-Strasse 1, 90419 Nuremberg, Germany
| | - Cândida Fonseca
- Department of Internal Medicine, Hospital S. Francisco Xavier/CHLO, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria 130, 1169-056 Lisbon, Portugal
| | - Sabine Genth-Zotz
- Department of Internal Medicine I, Katholisches Klinikum Mainz, An der Goldrube 11, 55131 Mainz, Germany
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, Universidad de Alcala, IRYCIS, Ctra. Colmenar Viejo, km. 9, 100, 28034 Madrid, Spain
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Department of Emergency Medicine and Services, Helsinki University Hospital, Tukholmankatu 8A, 00290 Helsinki, Finland
| | - Matthias Held
- Department of Internal Medicine, Medical Mission Hospital, Academic Teaching Hospital of the Julius-Maximilian University of Wuerzburg, Josef-Schneider-Strasse 2, 97080 Wuerzburg, Germany
| | - Lorenzo Iogna Prat
- Department of Emergency Medicine, Santa Maria della Misericordia Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
| | - Tobias J Lange
- Department of Internal Medicine II, Division of Pneumology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Athanasios Manolis
- Department of Cardiology, General Hospital 'Asklepeion Voulas', Leof. Vasileos Pavlou 1, 166 73 Athens, Greece
| | - Andreas Meyer
- Kliniken Maria Hilf, Klinik für Pneumologie, Krankenhaus St. Franziskus, Viersener Str. 450, 41063 Mönchengladbach, Germany
| | - Pirjo Mustonen
- Department of Medicine, Keski-Suomi Central Hospital and University of Jyväskylä, Keskussairaalantie 19, 40620 Jyväskylä, Finland
| | - Ursula Rauch-Kroehnert
- Department of Cardiology, University Heart Center Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Pedro Ruiz-Artacho
- Emergency Department, Clinico San Carlos Hospital, IdISSC, alle del Prof Martín Lagos, s/n, 28040 Madrid, Spain.,Internal Medicine Department, University Clinic of Navarra, Calle Marquesado de Sta. Marta 1, 28027 Madrid, Spain
| | - Sebastian Schellong
- Vascular Center, Municipal Hospital of Dresden-Friedrichstadt, Friedrichstraße 41, 01067 Dresden, Germany
| | - Martin Schwaiblmair
- Department of Cardiology, Respiratory Medicine and Intensive Care, Klinikum Augsburg, Ludwig-Maximilians-University Munich, Stenglinstrasse 2, 86156 Munich, Germany
| | - Raoul Stahrenberg
- Helios Albert-Schweitzer-Klinik, Albert-Schweitzer-Weg 1, 37154 Northeim, Germany
| | - Peter E Westerweel
- Department of Internal Medicine, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands
| | - Philipp S Wild
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany.,Center for Cardiology, Preventive Cardiology and Preventive Medicine, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité - University Medicine Berlin, Augustenburgerplatz 1, 13353 Berlin, Germany.,Clinic of Cardiology and Pneumology, Heart Center, University Medical Center Goettingen, Robert-Koch-Strasse 40, 37075 Goettingen, Germany
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9
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2021; 41:543-603. [PMID: 31504429 DOI: 10.1093/eurheartj/ehz405] [Citation(s) in RCA: 1975] [Impact Index Per Article: 658.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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10
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Triantafyllou GA, O'Corragain O, Rivera-Lebron B, Rali P. Risk Stratification in Acute Pulmonary Embolism: The Latest Algorithms. Semin Respir Crit Care Med 2021; 42:183-198. [PMID: 33548934 DOI: 10.1055/s-0041-1722898] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pulmonary embolism (PE) is a common clinical entity, which most clinicians will encounter. Appropriate risk stratification of patients is key to identify those who may benefit from reperfusion therapy. The first step in risk assessment should be the identification of hemodynamic instability and, if present, urgent patient consideration for systemic thrombolytics. In the absence of shock, there is a plethora of imaging studies, biochemical markers, and clinical scores that can be used to further assess the patients' short-term mortality risk. Integrated prediction models incorporate more information toward an individualized and precise mortality prediction. Additionally, bleeding risk scores should be utilized prior to initiation of anticoagulation and/or reperfusion therapy administration. Here, we review the latest algorithms for a comprehensive risk stratification of the patient with acute PE.
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Affiliation(s)
- Georgios A Triantafyllou
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Oisin O'Corragain
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania
| | - Belinda Rivera-Lebron
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania
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11
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Maughan BC, Frueh L, McDonagh MS, Casciere B, Kline JA. Outpatient Treatment of Low-risk Pulmonary Embolism in the Era of Direct Oral Anticoagulants: A Systematic Review. Acad Emerg Med 2021; 28:226-239. [PMID: 32779290 DOI: 10.1111/acem.14108] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/27/2020] [Accepted: 08/07/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Clinical guidelines have supported outpatient treatment of low-risk pulmonary embolism (PE) since 2014, but adoption of this practice has been slow. Direct oral anticoagulant (DOAC) therapy for venous thromboembolism (VTE) is now as common as vitamin K antagonist treatment, but data are sparse regarding outcomes for patients with low-risk PE treated with DOACs as outpatients. We conducted a systematic review of literature on outcomes of outpatient management for PE, including comparisons to inpatient treatment and differences by anticoagulant class. METHODS We searched Medline, Embase, PubMed, CENTRAL, clinicaltrials.gov, and ICTRN for studies published from January 1980 through February 2019 using a predefined strategy developed with a medical librarian. We included English-language randomized controlled trials (RCTs) and prospective nonrandomized trials (NRTs) of adult patients diagnosed with acute, symptomatic PE, and discharged from the emergency department or within 48 hours. Our primary outcome included four major adverse outcomes (all-cause mortality, PE-related mortality, recurrent VTE, and major bleeding) within 30 and 90 days. A preplanned subanalysis of high-quality studies assessed outcomes associated with different anticoagulation treatment classes. RESULTS Our initial search identified 6,818 records, of which 12 studies (four RCT, eight NRT) with a total of 3,191 patients were included in the review. All RCTs and six NRTs were determined to have low to moderate risk of bias and were classified as high quality. Outpatients in these studies (n = 1,814) had rates of 90-day major adverse outcomes below 1%, including all-cause mortality (0.7%, 95% confidence interval [CI] = 0.4% to 1.2%), PE-related mortality (0.06%, 95% CI = 0.01% to 0.3%), recurrent VTE (0.8%, 95% CI = 0.5% to 1.4%), and major bleeding (0.8%, 95% CI = 0.5% to 1.4%). Exploratory analysis revealed no association between anticoagulant treatment class and rates of major adverse outcomes. CONCLUSION Among patients with low-risk PE treated as outpatients, few patients experienced major adverse outcomes such as mortality, recurrent VTE, or major bleeding within 90 days.
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Affiliation(s)
- Brandon C. Maughan
- From the Department of Emergency Medicine Oregon Health & Science University School of Medicine Portland ORUSA
| | - Lisa Frueh
- and the Department of Social and Behavioral Sciences Harvard TS Chan School of Public Health Boston MAUSA
| | - Marian S. McDonagh
- the Department of Medical Informatics and Clinical Epidemiology Oregon Health & Science University School of Medicine Portland ORUSA
| | - Bryan Casciere
- From the Department of Emergency Medicine Oregon Health & Science University School of Medicine Portland ORUSA
| | - Jeffrey A. Kline
- and the Department of Emergency Medicine Indiana University School of Medicine Indianapolis INUSA
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12
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Abstract
Acute pulmonary embolism (PE) is the third most common acute cardiovascular condition, and its prevalence increases over time. D-dimer has a very high negative predictive value, and if normal levels of D-dimer are detected, the diagnosis of PE is very unlikely. The final diagnosis should be confirmed by computed tomographic scan. However, echocardiography is the most available, bedside, low-cost, diagnostic procedure for patients with PE. Risk stratification is of utmost importance and is mainly based on hemodynamic status of the patient. Patients with PE and hemodynamic stability require further risk assessment, based on clinical symptoms, imaging, and circulating biomarkers.
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13
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Condliffe R, Albert P, Alikhan R, Gee E, Horner D, Hunter L, Jacobs P, Limbrey R, Newnham M, Preston W, Patel S, Smith LJ, Suntharalingam J. British Thoracic Society Quality Standards for outpatient management of pulmonary embolism. BMJ Open Respir Res 2020; 7:7/1/e000636. [PMID: 32816797 PMCID: PMC7437715 DOI: 10.1136/bmjresp-2020-000636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The purpose of the quality standards document is to provide healthcare professionals, commissioners, service providers and patients with a guide to standards of care that should be met for outpatient management of pulmonary embolism in the UK, together with measurable markers of good practice. Quality statements are based on the British Thoracic Society (BTS) Guideline for the Initial Outpatient Management of Pulmonary Embolism. METHODS Development of BTS Quality Standards follows the BTS process of quality standard production based on the National Institute for Health and Care Excellence process manual for the development of quality standards. RESULTS Six quality statements have been developed, each describing a standard of care for the outpatient management of pulmonary embolism in the UK, together with measurable markers of good practice. DISCUSSION BTS Quality Standards for Outpatient Management of Pulmonary Embolism form a key part of the range of supporting materials that the society produces to assist in the dissemination and implementation of a guideline's recommendations.
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Affiliation(s)
- Robin Condliffe
- Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Paul Albert
- Respiratory Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Raza Alikhan
- Haematology, University Hospital of Wales, Cardiff, UK
| | - Emma Gee
- Thrombosis and Coagulation, King's College Hospital, London, UK
| | - Daniel Horner
- Emergency Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Laura Hunter
- Emergency Medicine, St Thomas' Hospital, London, UK
| | | | - Rachel Limbrey
- Respiratory Medicine, Southampton General Hospital, Southampton, UK
| | - Michael Newnham
- Respiratory Medicine, Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Wendy Preston
- Respiratory Medicine, George Eliot Hospital NHS Trust, Nuneaton, Warwickshire, UK
| | - Sheena Patel
- Anticoagulation and Medication Safety/Clinical Governance, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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14
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Barco S, Mahmoudpour SH, Planquette B, Sanchez O, Konstantinides SV, Meyer G. Prognostic value of right ventricular dysfunction or elevated cardiac biomarkers in patients with low-risk pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2020; 40:902-910. [PMID: 30590531 PMCID: PMC6416533 DOI: 10.1093/eurheartj/ehy873] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/14/2018] [Accepted: 12/03/2018] [Indexed: 12/22/2022] Open
Abstract
Aims Patients with acute pulmonary embolism (PE) classified as low risk by the Pulmonary Embolism Severity Index (PESI), its simplified version (sPESI), or the Hestia criteria may be considered for early discharge. We investigated whether the presence of right ventricular (RV) dysfunction may aggravate the early prognosis of these patients. Methods and results We did a systematic review and meta-analysis of studies including low-risk patients with acute PE to investigate the prognostic value of RV dysfunction. Diagnosis of RV dysfunction was based on echocardiography or computed tomography pulmonary angiography. In addition, we investigated the prognostic value of elevated troponin or natriuretic peptide levels. The primary outcome was all-cause mortality at 30 days or during hospitalization. We included 22 studies (N = 3295 low-risk patients) in the systematic review: 21 were selected for quantitative analysis. Early all-cause mortality rates in patients with vs. without RV dysfunction on imaging were 1.8% [95% confidence interval (CI) 0.9–3.5%] vs. 0.2% (95% CI 0.03–1.7%), respectively, [odds ratio (OR) 4.19, 95% CI 1.39–12.58]. For troponins, rates were 3.8% (95% CI 2.1–6.8%) vs. 0.5% (95% CI 0.2–1.3%), (OR 6.25, 95% CI 1.95–20.05). For natriuretic peptides, only data on early PE-related mortality were available: rates were 1.7% (95% CI 0.4–6.9%) vs. 0.4% (95% CI 0.1–1.1%), (OR 3.71, 95% CI 0.81–17.02). Conclusions In low-risk patients with acute PE, the presence of RV dysfunction on admission was associated with early mortality. Our results may have implications for the management of patients who appear at low risk based on clinical criteria alone, but present with RV dysfunction as indicated by imaging findings or laboratory markers.
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Affiliation(s)
- Stefano Barco
- Center for Thrombosis and Haemostasis (CTH), University Medical Centre of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany
- Corresponding author. Tel: +49 6131 17 8251, Fax: +49 6131 17 8461,
| | - Seyed Hamidreza Mahmoudpour
- Center for Thrombosis and Haemostasis (CTH), University Medical Centre of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany
- Department of Biometry and Bioinformatics, Institute for Medical Biostatistics, Epidemiology, and Informatics (IMBEI), University Medical Centre of the Johannes Gutenberg University, Obere Zahlbacher Straße 69, Mainz, Germany
| | - Benjamin Planquette
- F-CRIN INNOVTE, Hôpital Nord, CHU Saint Etienne, Avenue Albert Raimond, Saint Priest en Jarez (Saint Etienne), France
- Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S 1140, 20 rue Leblanc, Paris, France
| | - Olivier Sanchez
- F-CRIN INNOVTE, Hôpital Nord, CHU Saint Etienne, Avenue Albert Raimond, Saint Priest en Jarez (Saint Etienne), France
- Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S 1140, 20 rue Leblanc, Paris, France
| | - Stavros V Konstantinides
- Center for Thrombosis and Haemostasis (CTH), University Medical Centre of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, University General Hospital, Alexandroupolis, Greece
| | - Guy Meyer
- F-CRIN INNOVTE, Hôpital Nord, CHU Saint Etienne, Avenue Albert Raimond, Saint Priest en Jarez (Saint Etienne), France
- Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S 1140, 20 rue Leblanc, Paris, France
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15
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Vinson DR, Bath H, Huang J, Reed ME, Mark DG. Hospitalization Is Less Common in Ambulatory Patients With Acute Pulmonary Embolism Diagnosed Before Emergency Department Referral Than After Arrival. Acad Emerg Med 2020; 27:588-599. [PMID: 32470189 DOI: 10.1111/acem.14034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 04/28/2020] [Accepted: 05/19/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Emergency department (ED) patients with acute pulmonary embolism (PE) may undergo diagnostic pulmonary imaging as an outpatient before referral to the ED for definitive management. This population has not been well characterized. METHODS This retrospective cohort study included ambulatory adults with acute objectively confirmed PE across 21 EDs in an integrated health care system from January 1, 2013, through April 30, 2015. We excluded patients arriving by ambulance. We compared outpatients with diagnostic pulmonary imaging in the 12 hours prior to ED arrival (the clinic-based cohort) with those receiving imaging for PE only after ED arrival. We reported adjusted odds ratio (aOR) with 95% confidence intervals (CIs) for hospitalization, adjusted for race, presyncope or syncope, proximal clot location, and PE Severity Index class. RESULTS Among 2,352 eligible ED patients with acute PE, 344 (14.6%) had a clinic-based diagnosis. This cohort had lower PE Severity Index classification and were less likely to be hospitalized than their counterparts with an ED-based diagnosis: 80.8% vs. 92.0% (p < 0.0001). The inverse association with hospitalization persisted after adjusting for the above patient characteristics with aOR of 0.36 (95% CI = 0.26 to 0.50). CONCLUSION In the study setting, ambulatory outpatients with acute PE are commonly diagnosed before ED arrival. A clinic-based diagnosis of PE identifies ED patients less likely to be hospitalized. Research is needed to identify which patients with a clinic-based PE diagnosis may not require transfer to the ED before home discharge.
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Affiliation(s)
- David R. Vinson
- From The Permanente Medical Group Oakland CA USA
- the Kaiser Permanente Division of Research Oakland CA USA
- the Kaiser Permanente Sacramento Medical Center Sacramento CA USA
| | | | - Jie Huang
- the Kaiser Permanente Division of Research Oakland CA USA
| | - Mary E. Reed
- the Kaiser Permanente Division of Research Oakland CA USA
| | - Dustin G. Mark
- From The Permanente Medical Group Oakland CA USA
- the Kaiser Permanente Division of Research Oakland CA USA
- and the Kaiser Permanente Oakland Medical Center Oakland CA USA
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16
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Hendriks SV, Bavalia R, van Bemmel T, Bistervels IM, Eijsvogel M, Faber LM, Fogteloo J, Hofstee HMA, van der Hulle T, Iglesias Del Sol A, Kruip MJHA, Mairuhu ATA, Middeldorp S, Nijkeuter M, Huisman MV, Klok FA. Current practice patterns of outpatient management of acute pulmonary embolism: A post-hoc analysis of the YEARS study. Thromb Res 2020; 193:60-65. [PMID: 32521336 DOI: 10.1016/j.thromres.2020.05.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/30/2020] [Accepted: 05/25/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Studies have shown the safety of home treatment of patients with pulmonary embolism (PE) at low risk of adverse events. Management studies focusing on home treatment have suggested that 30% to 55% of acute PE patients could be treated at home, based on the HESTIA criteria, but data from day-to-day clinical practice are largely unavailable. AIM To determine current practice patterns of home treatment of acute PE in the Netherlands. METHOD We performed a post-hoc analysis of the YEARS study. The main outcomes were the proportion of patients who were discharged <24 h and reasons for admission if treated in hospital. Further, we compared the 3-month incidence of PE-related unscheduled readmissions between patients treated at home and in hospital. RESULTS Of the 404 outpatients with PE included in this post-hoc analysis of the YEARS study, 184 (46%) were treated at home. The median duration of admission of the hospitalized patients was 3.0 days. The rate of PE-related readmissions of patients treated at home was 9.7% versus 8.6% for hospitalized patients (crude hazard ratio 1.1 (95% CI 0.57-2.1)). The 3-month incidence of any adverse event was 3.8% in those treated at home (2 recurrent VTE, 3 major bleedings and two deaths) compared to 10% in the hospitalized patients (3 recurrent VTE, 6 major bleedings and fourteen deaths). CONCLUSIONS In the YEARS study, 46% of patients with PE were treated at home with low incidence of adverse events. PE-related readmission rates were not different between patients treated at home or in hospital.
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Affiliation(s)
- Stephan V Hendriks
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands.
| | - Roisin Bavalia
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Thomas van Bemmel
- Department of Internal Medicine, Gelre Hospital, Apeldoorn, the Netherlands
| | - Ingrid M Bistervels
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Department of Internal Medicine, Flevoziekenhuis, Almere, the Netherlands
| | - Michiel Eijsvogel
- Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Laura M Faber
- Department of Pulmonary Medicine, Rode Kruis Hospital, Beverwijk, the Netherlands
| | - Jaap Fogteloo
- Department of Acute Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Herman M A Hofstee
- Department of Internal Medicine, HMC Westeinde/Bronono, The Hague, the Netherlands
| | - Tom van der Hulle
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical center, Rotterdam, the Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Mathilde Nijkeuter
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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17
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Vinson DR, Aujesky D, Geersing GJ, Roy PM. Comprehensive Outpatient Management of Low-Risk Pulmonary Embolism: Can Primary Care Do This? A Narrative Review. Perm J 2020; 24:19.163. [PMID: 32240089 DOI: 10.7812/tpp/19.163] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The evidence for outpatient management of hemodynamically stable, low-risk patients with acute symptomatic pulmonary embolism (PE) is mounting. Guidance in identifying patients who are eligible for outpatient (ambulatory) care is available in the literature and society guidelines. Less is known about who can identify patients eligible for outpatient management and in what clinical practice settings. OBJECTIVE To answer the question, "Can primary care do this?" (provide comprehensive outpatient management of low-risk PE). METHODS We undertook a narrative review of the literature on the outpatient management of acute PE focusing on site of care. We searched the English-language literature in PubMed and Embase from January 1, 1950, through July 15, 2019. RESULTS We identified 26 eligible studies. We found no studies that evaluated comprehensive PE management in a primary care clinic or general practice setting. In 19 studies, the site-of-care decision making occurred in the Emergency Department (or after a short period of supplemental observation) and in 7 studies the decision occurred in a specialty clinic. We discuss the components of care involved in the diagnosis, outpatient eligibility assessment, treatment, and follow-up of ambulatory patients with acute PE. DISCUSSION We see no formal reason why a trained primary care physician could not provide comprehensive care for select patients with low-risk PE. Leading obstacles include lack of ready access to advanced pulmonary imaging and the time constraints of a busy outpatient clinic. CONCLUSION Until studies establish safe parameters of such a practice, the question "Can primary care do this?" must remain open.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA.,Kaiser Permanente Division of Research, Oakland, CA.,Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, CA
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, UMR (CNRS 6015 - INSERM 1083) Institut Mitovasc, Université d'Angers, France
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18
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Simona A, Limacher A, Méan M, Golaz O, Bounameaux H, Aujesky D, Righini M, Vuilleumier N. High-sensitive cardiac troponin T as a marker of hemorrhagic complications in elderly patients anticoagulated for non-massive pulmonary embolism. Thromb Res 2019; 185:5-12. [PMID: 31731089 DOI: 10.1016/j.thromres.2019.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Recent data have raised concerns about the risk/benefit ratio of thrombolysis in non-high risk pulmonary embolism patients due to increased serious bleeding events. Whether cardiac biomarkers could be of help for bleeding risk stratification in this setting remains elusive. OBJECTIVES To determine the prognostic accuracy of hs-cTnT, NT-proBNP, RIETE and PESI score for the occurrence of clinically relevant bleeding (CRB) in elderly patients under conventional anticoagulation therapy for non-massive pulmonary embolism (NMPE). METHODS We evaluated 230 elderly patients with available blood sample taken within one day from diagnosis. The primary study endpoint was CRB at 1, 3 and 24 months. Prognostic accuracies and associations were determined using C-statistics and subhazard ratios (SHR), respectively. RESULTS hs-cTnT displayed the highest discriminatory power at 1 month (C-statistics: 0.77, 95% CI: 0.68-0.88) which remained stable over time. Although C-statistics comparison indicated that hs-cTnT was not statistically superior to RIETE score (0.77 vs 0.67, p = 0.11), adding hs-cTnT to RIETE score significantly improved the C-statistics from 0.67 to 0.78 (p = 0.02). SHRs indicated that for each hs-cTnT log-unit increase, there was a 58% increase in the risk of CRB independently of the RIETE score (adjusted SHR: 1.58, 95% CI: 1.31-1.92). At the pre-specified cut-off of 14 ng/l, the negative predictive value of hs-cTnT was 96.9% (95% CI: 91.4-99.0) and 94.9 (95%CI: 88.6-97.8) at 1 and 3 months, respectively. CONCLUSION In elderly, hs-cTnT provides incremental prognostic information over the RIETE score and could represent a valuable tool to identify NMPE patients at low risk of bleeding.
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Affiliation(s)
- Aurélien Simona
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | - Andreas Limacher
- CTU Bern and Department of Clinical Research, Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Marie Méan
- Division of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Olivier Golaz
- Division on Laboratory Medicine, Diagnostics Department and Department of Internal Medicine Specialities, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Henri Bounameaux
- Division of Angiology and Haemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Drahomir Aujesky
- Division of General Internal Medicine, Bern University Hospital and University of Bern, Switzerland
| | - Marc Righini
- Division of Angiology and Haemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Nicolas Vuilleumier
- Division on Laboratory Medicine, Diagnostics Department and Department of Internal Medicine Specialities, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland.
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Home treatment of patients with cancer-associated venous thromboembolism - An evaluation of daily practice. Thromb Res 2019; 184:122-128. [PMID: 31731069 DOI: 10.1016/j.thromres.2019.10.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/25/2019] [Accepted: 10/31/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Home treatment of cancer-associated venous thromboembolism (VTE) is challenging due to the high risk of adverse events. While home treatment is quite agreeable to cancer patients, studies evaluating the safety of VTE home treatment in this setting are largely unavailable. METHODS This was an observational study in patients with cancer-associated VTE. The main outcomes were the proportion of patients treated at home (hospital discharge <24 h after diagnosis) and the 3-month incidence of VTE-related adverse events (major bleeding, recurrent VTE and/or suspected VTE-related mortality) in patients managed in hospital versus at home. RESULTS A total of 183 outpatients were diagnosed with cancer-associated VTE: 69 had deep vein thrombosis (DVT) and 114 had pulmonary embolism (PE ± DVT). Of those, 120 (66%) were treated at home; this was 83% for patients with DVT and 55% for patients with PE (±DVT). The 3-month incidence of any VTE-related adverse event was 13% in those treated at home versus 19% in the hospitalized patients (HR 0.48; 95%CI 0.22-1.1), independent of initial presentation as PE or DVT. All-cause 3-month mortality occurred in 33 patients treated as inpatient (54%) compared to 29 patients treated at home (24%; crude HR 3.1 95%CI 1.9-5.0). CONCLUSIONS Two-third of patients with cancer-associated VTE - including PE - were selected to start anticoagulant treatment at home. Cancer-associated VTE is associated with high rates of VTE-related adverse events independent of initial in hospital or home treatment. However, home treatment may be a good option for selected patients with cancer-associated DVT or PE.
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Bertoletti L, Delluc A, Frappé P, Roy PM, Sanchez O. [What route of care to propose to patients suffering from pulmonary embolism ? Who to treat as an outpatient ?]. Rev Mal Respir 2019; 38 Suppl 1:e74-e85. [PMID: 31611027 DOI: 10.1016/j.rmr.2019.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- L Bertoletti
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; Inserm UMR 1059, Inserm CIC-1408, équipe dysfonction vasculaire et hémostase, service de médecine vasculaire et thérapeutique, université Jean-Monnet, CHU de Saint-Étienne, 42000 Saint-Étienne, France
| | - A Delluc
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; EA 3878 GETBO, université de Bretagne occidentale, 29200 Brest, France
| | - P Frappé
- Inserm UMR 1059 Sainbiose DVH, Inserm CIC-EC 1408, département de médecine générale, université de Saint-Étienne, 42000 Saint-Étienne, France
| | - P-M Roy
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; Département de médecine d'urgence, service de médecine vasculaire, CHU d'Angers, 49000 Angers, France; Institut Mitovasc, UMR 1083, UFR santé, université d'Angers, 49000 Angers, France
| | - O Sanchez
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; Service de pneumologie et de soins intensifs, université de Paris, AH-HP, Sorbonne Paris-Cité, hôpital Européen Georges-Pompidou, Assistance publique-hôpitaux de Paris, 20, rue Leblanc, 75015 Paris, France; Innovations thérapeutiques en hémostase, Inserm UMRS 1140, 75006 Paris, France.
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Hepburn-Brown M, Darvall J, Hammerschlag G. Acute pulmonary embolism: a concise review of diagnosis and management. Intern Med J 2019; 49:15-27. [PMID: 30324770 DOI: 10.1111/imj.14145] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 09/27/2018] [Accepted: 10/01/2018] [Indexed: 12/14/2022]
Abstract
An acute pulmonary embolism (aPE) is characterised by occlusion of one or more pulmonary arteries. Physiological disturbance may be minimal, but often cardiac output decreases as the right ventricle attempts to overcome increased afterload. Additionally, ventilation-perfusion mismatches can develop in affected vascular beds, reducing systemic oxygenation. Incidence is reported at 50-75 per 100 000 in Australia and New Zealand, with 30-day mortality rates ranging from 0.5% to over 20%. Incidence is likely to increase with the ageing population, increased survival of patients with comorbidities that are considered risk factors and improving sensitivity of imaging techniques. Use of clinical prediction scores, such as the Wells score, has assisted in clinical decision-making and decreased unnecessary radiological investigations. However, imaging (i.e. computed tomography pulmonary angiography or ventilation-perfusion scans) is still necessary for objective diagnosis. Anti-coagulation remains the foundation of PE management. Haemodynamically unstable patients require thrombolysis unless absolutely contraindicated, while stable patients with right ventricular dysfunction or ischaemia should be aggressively anti-coagulated. Stable patients with no right ventricular dysfunction can be discharged home early with anti-coagulation and review. However, treatment should be case dependent with full consideration of the patient's clinical state. Direct oral anti-coagulants have become an alternative to vitamin K antagonists and are facilitating shorter hospital admissions. Additionally, duration of anti-coagulation must be decided by considering any provoking factors, bleeding risk and comorbid state. Patients with truly unprovoked or idiopathic PE often require indefinite treatment, while in provoked cases it is typically 3 months with some patients requiring longer periods of 6-12 months.
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Affiliation(s)
- Morgan Hepburn-Brown
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Jai Darvall
- Department of Intensive Care and Anaesthesia/Pain Management, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Gary Hammerschlag
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Áinle FN, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Respir J 2019; 54:13993003.01647-2019. [DOI: 10.1183/13993003.01647-2019] [Citation(s) in RCA: 509] [Impact Index Per Article: 101.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Peacock WF, Singer AJ. Reducing the hospital burden associated with the treatment of pulmonary embolism. J Thromb Haemost 2019; 17:720-736. [PMID: 30851227 PMCID: PMC6849869 DOI: 10.1111/jth.14423] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Indexed: 12/14/2022]
Abstract
Pulmonary embolism (PE) is the most feared clinical presentation of venous thromboembolism (VTE). Patients with PE have traditionally been treated in hospital; however, many are at low risk of adverse outcomes and current guidelines suggest outpatient treatment as an option. Outpatient treatment of PE offers several advantages, including reduced risk of hospital-acquired conditions and potential cost savings. Despite this, patients with low-risk PE are still frequently hospitalized for treatment. This narrative review summarizes current guideline recommendations for the identification of patients with low-risk PE who are potentially suitable for outpatient treatment, using prognostic assessment tools (e.g. the Pulmonary Embolism Severity Index [PESI] and simplified PESI) and clinical exclusion criteria (e.g. Hestia criteria) alone or in combination with additional cardiac assessments. Treatment options are discussed along with recommendations for the follow-up of patients managed in the non-hospital environment. The available data on outpatient treatment of PE are summarized, including details on patient selection, anticoagulant choice, and short-term outcomes in each study. Accumulating evidence suggests that outcomes in patients with low-risk PE treated as outpatients are at least as good as, if not better than, those of patients treated in the hospital. With mounting pressures on health care systems worldwide, increasing the proportion of patients with PE treated as outpatients has the potential to reduce health care burdens associated with VTE.
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Affiliation(s)
- W. Frank Peacock
- Department of Emergency MedicineBaylor College of MedicineHoustonTXUSA
| | - Adam J. Singer
- Department of Emergency MedicineStony Brook School of MedicineStony BrookNYUSA
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Reschen ME, Raby J, Bowen J, Singh S, Lasserson D, O'Callaghan CA. A retrospective analysis of outcomes in low- and intermediate-high-risk pulmonary embolism patients managed on an ambulatory medical unit in the UK. ERJ Open Res 2019; 5:00184-2018. [PMID: 30972349 PMCID: PMC6452043 DOI: 10.1183/23120541.00184-2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/28/2019] [Indexed: 12/16/2022] Open
Abstract
Pulmonary embolism (PE) is common and guidelines recommend outpatient care only for PE patients with low predicted mortality. Outcomes for patients with intermediate-to-high predicted mortality managed as outpatients are unknown. Electronic records were analysed for adults with PE managed on our ambulatory care unit over 2 years. Patients were stratified into low or intermediate-to-high mortality risk groups using the Pulmonary Embolism Severity Index (PESI). Primary outcomes were the proportion of patients ambulated, 30-day all-cause mortality, 30-day PE-specific mortality and 30-day re-admission rate. Of 199 PE patients, 74% were ambulated and at 30 days, all-cause mortality was 2% (four out of 199) and PE-specific mortality was 1% (two out of 199). Ambulated patients had lower PESI scores, better vital signs and lower troponin levels (morning attendance favoured ambulation). Over a third of ambulated patients had an intermediate-to-high risk PESI score but their all-cause mortality rate was low at 1.9% (one out of 52). In patients with intermediate-to-high risk, oxygen saturation was higher and pulse rate lower in those who were ambulated. Re-admission rate did not differ between ambulated and admitted patients. Two-thirds of patients with intermediate-to-high risk PE were ambulated and their mortality rate remained low. It is possible for selected patients with intermediate-to-high risk PESI scores to be safely ambulated.
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Affiliation(s)
- Michael E. Reschen
- Dept of Acute General Medicine, John Radcliffe Hospital, Oxford University NHS Hospitals Foundation Trust, Oxford, UK
| | - Jonathan Raby
- Dept of Acute General Medicine, John Radcliffe Hospital, Oxford University NHS Hospitals Foundation Trust, Oxford, UK
| | - Jordan Bowen
- Dept of Acute General Medicine, John Radcliffe Hospital, Oxford University NHS Hospitals Foundation Trust, Oxford, UK
| | - Sudhir Singh
- Dept of Acute General Medicine, John Radcliffe Hospital, Oxford University NHS Hospitals Foundation Trust, Oxford, UK
| | - Daniel Lasserson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Yoo HHB, Nunes‐Nogueira VS, Fortes Villas Boas PJ, Broderick C. Outpatient versus inpatient treatment for acute pulmonary embolism. Cochrane Database Syst Rev 2019; 3:CD010019. [PMID: 30839095 PMCID: PMC6402388 DOI: 10.1002/14651858.cd010019.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is a common life-threatening cardiovascular condition, with an incidence of 23 to 69 new cases per 100,000 people each year. For selected low-risk patients with acute PE, outpatient treatment might provide several advantages over traditional inpatient treatment, such as reduction of hospitalisations, substantial cost savings, and improvements in health-related quality of life. This is an update of the review first published in 2014. OBJECTIVES To compare the efficacy and safety of outpatient versus inpatient treatment in low-risk patients with acute PE for the outcomes of all-cause and PE-related mortality; bleeding; adverse events such as haemodynamic instability; recurrence of PE; and patients' satisfaction. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers, to 26 March 2018. We also undertook reference checking to identify additional studies. SELECTION CRITERIA We included randomised controlled trials of outpatient versus inpatient treatment of adults (aged 18 years and over) diagnosed with low-risk acute PE. DATA COLLECTION AND ANALYSIS Two review authors selected relevant trials, assessed methodological quality, and extracted and analysed data. We calculated effect estimates using risk ratio (RR) with 95% confidence intervals (CIs), or mean differences (MDs) with 95% CIs. We used standardised mean differences (SMDs) to combine trials that measured the same outcome but used different methods. We assessed the quality of the evidence using GRADE criteria. MAIN RESULTS One new study was identified for this 2018 update, bringing the total number of included studies to two and the total number of participants to 451. Both trials discharged patients randomised to the outpatient group within 36 hours of initial triage and both followed participants for 90 days. One study compared the same treatment regimens in both outpatient and inpatient groups, and the other study used different treatment regimes. There was no clear difference in treatment effect for the outcomes of short-term mortality (30 days) (RR 0.33, 95% CI 0.01 to 7.98, P = 0.49; low-quality evidence), long-term mortality (90 days) (RR 0.98, 95% CI 0.06 to 15.58, P = 0.99, low-quality evidence), major bleeding at 14 days (RR 4.91, 95% CI 0.24 to 101.57, P = 0.30; low-quality evidence) and at 90 days (RR 6.88, 95% CI 0.36 to 132.14, P = 0.20; low-quality evidence), minor bleeding (RR 1.08, 95% CI 0.07 to 16.79; P = 0.96, low-quality evidence), recurrent PE within 90 days (RR 2.95, 95% CI 0.12 to 71.85, P = 0.51, low-quality evidence), and participant satisfaction (RR 0.97, 95% CI 0.90 to 1.04, P = 0.39; moderate-quality evidence). We downgraded the quality of the evidence because the CIs were wide and included treatment effects in both directions, the sample sizes and numbers of events were small, and because the effect of missing data and the absence of publication bias could not be verified. PE-related mortality, and adverse effects such as haemodynamic instability and compliance, were not assessed by the included studies. AUTHORS' CONCLUSIONS Currently, only low-quality evidence is available from two published randomised controlled trials on outpatient versus inpatient treatment in low-risk patients with acute PE. The studies did not provide evidence of any clear difference between the interventions in overall mortality, bleeding and recurrence of PE.
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Affiliation(s)
- Hugo HB Yoo
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Vania Santos Nunes‐Nogueira
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Paulo J Fortes Villas Boas
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Cathryn Broderick
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsTeviot PlaceEdinburghUKEH8 9AG
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Pouzet G, Dubie E, Belle L, Lesage P, Usseglio P. [Evaluation of the management of low-risk pulmonary embolism diagnosed in an emergency department. HoPE study (Home treatment of Pulmonary Embolism)]. Ann Cardiol Angeiol (Paris) 2019; 68:1-5. [PMID: 30292444 DOI: 10.1016/j.ancard.2018.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 08/07/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Risk stratification allows outpatient management of low-risk pulmonary embolism (PE). Here, we carry out an evaluation of the professional practices on the emergency management of low-risk PE, after selection with the sPESI score. MATERIAL AND METHOD All patients admitted to the emergency department of Chambéry hospital, with a final diagnosis of PE are analyzed. The PE of score sPESI at 0 are included, in the absence of contraindications. Ninety-day follow-up is done. The objective is to evaluate the proportion of ambulatory care for low-risk patients. RESULTS Eighty PE were diagnosed in 2016, 28 with sPESI score at 0 and 3 patients excluded. Of the 25 inclusions, 6 patients had signs of right ventricular dysfunction and were therefore hospitalized. The remaining 19 were eligible for outpatient care but only 8 of them stayed less than 24hours in the hospital. DISCUSSION The sPESI score is a decision support tool for outpatient management but should not be used alone. The search for right ventricular dysfunction seems important here.
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Affiliation(s)
- G Pouzet
- Urgence/SAMU/SMUR, centre hospitalier Métropole Savoie, 505, faubourg Maché, 73000 Chambéry, France.
| | - E Dubie
- Urgence/SAMU/SMUR, centre hospitalier Métropole Savoie, 505, faubourg Maché, 73000 Chambéry, France
| | - L Belle
- Cardiologie, centre hospitalier Annecy-Genevois, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - P Lesage
- Urgence/SAMU/SMUR, centre hospitalier Métropole Savoie, 505, faubourg Maché, 73000 Chambéry, France
| | - P Usseglio
- Urgence/SAMU/SMUR, centre hospitalier Métropole Savoie, 505, faubourg Maché, 73000 Chambéry, France
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27
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Peacock WF, Coleman CI, Wells P, Fermann GJ, Wang L, Baser O, Schein J, Crivera C. Clinical and Economic Outcomes in Low-risk Pulmonary Embolism Patients Treated with Rivaroxaban versus Standard of Care. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2019; 6:160-173. [PMID: 32685588 PMCID: PMC7299482 DOI: 10.36469/9936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND Rivaroxaban, a fixed-dose oral direct factor Xa inhibitor, does not require continuous monitoring and thus reduces the hospital stay and economic burden in low-risk pulmonary embolism (LRPE) patients. Study Question: What is the effectiveness of rivaroxaban versus the standard of care (SOC; low-molecular-weight heparin, unfractionated heparin, warfarin) among LRPE patients in the Veterans Health Administration? STUDY DESIGN Adult patients with continuous health plan enrollment for ≥12 months pre- and 3 months post-inpatient PE diagnosis (index date=discharge date) between October 1, 2011-June 30, 2015 and an anticoagulant claim during the index hospitalization were included. MEASURES AND OUTCOMES Patients scoring 0 points on the simplified Pulmonary Embolism Stratification Index were considered low-risk and were stratified into SOC and rivaroxaban cohorts. Propensity score matching (PSM) was used to compare hospital-acquired complications (HACs), PE-related outcomes (recurrent venous thromboembolism, major bleeding, and death), and healthcare utilization and costs between the rivaroxaban and SOC cohorts. RESULTS Among 6746 PE patients, 1918 were low-risk; of these, 73 were prescribed rivaroxaban, 1546 were prescribed SOC, and 299 were prescribed other anticoagulants during the index hospitalization. After 1:3 PSM, 64 rivaroxaban and 192 SOC patients were included. During the index hospitalization, rivaroxaban users (versus SOC) had similar inpatient length of stay (LOS; 7.0 vs 6.7 days, standardized difference [STD]=1.8) but fewer HACs (4.7% vs 10.4%; STD: 21.7). In the 90-day post-discharge period, PE-related outcome rates were similar between the cohorts (all p>0.05). However, rivaroxaban users had fewer outpatient (15.9 vs 20.4; p=0.0002) visits per patient as well as lower inpatient ($765 vs $2,655; p<0.0001), pharmacy ($711 vs $1,086; p=0.0033), and total costs ($6,270 vs $9,671; p=0.0027). CONCLUSIONS LRPE patients prescribed rivaroxaban had similar index LOS and PE-related outcomes, but fewer HACs, and lower total costs than those prescribed SOC.
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Affiliation(s)
| | | | - Phil Wells
- Institution: University of Ottawa and the Ottawa Hospital Research Institute
| | | | - Li Wang
- Institution: STATinMED Research
| | | | - Jeff Schein
- Institution: Janssen Scientific Affairs, LLC
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Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Acute Venous Thromboembolic Disease. Ann Emerg Med 2018; 71:e59-e109. [PMID: 29681319 DOI: 10.1016/j.annemergmed.2018.03.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Simon LE, Iskin HR, Vemula R, Huang J, Rauchwerger AS, Reed ME, Ballard DW, Vinson DR. Emergency Department Patient Satisfaction with Treatment of Low-risk Pulmonary Embolism. West J Emerg Med 2018; 19:938-946. [PMID: 30429925 PMCID: PMC6225929 DOI: 10.5811/westjem.2018.9.38865] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/29/2018] [Accepted: 09/07/2018] [Indexed: 11/11/2022] Open
Abstract
Introduction Many emergency department (ED) patients with acute pulmonary embolism (PE) who meet low-risk criteria may be eligible for a short length of stay (LOS) (<24 hours), with expedited discharge home either directly from the ED or after a brief observation or hospitalization. We describe the association between expedited discharge and site of discharge on care satisfaction and quality of life (QOL) among patients with low-risk PE (PE Severity Index [PESI] Classes I-III). Methods This phone survey was conducted from September 2014 through April 2015 as part of a retrospective cohort study across 21 community EDs in Northern California. We surveyed low-risk patients with acute PE, treated predominantly with enoxaparin bridging and warfarin. All eligible patients were called 2-8 weeks after their index ED visit. PE-specific, patient-satisfaction questions addressed overall care, discharge instruction clarity, and LOS. We scored physical and mental QOL using a modified version of the validated Short Form Health Survey. Satisfaction and QOL were compared by LOS. For those with expedited discharge, we compared responses by site of discharge: ED vs. hospital, which included ED-based observation units. We used chi-square and Wilcoxon rank-sum tests as indicated. Results Survey response rate was 82.3% (424 of 515 eligible patients). Median age of respondents was 64 years; 47.4% were male. Of the 145 patients (34.2%) with a LOS<24 hours, 65 (44.8%) were discharged home from the ED. Of all patients, 89.6% were satisfied with their overall care and 94.1% found instructions clear. Sixty-six percent were satisfied with their LOS, whereas 17.5% would have preferred a shorter LOS and 16.5% a longer LOS. There were no significant differences in satisfaction between patients with LOS<24 hours vs. ≥24 hours (p>0.13 for all). Physical QOL scores were significantly higher for expedited-discharge patients (p=0.01). Patients with expedited discharge home from the ED vs. the hospital had no significant difference in satisfaction (p>0.20 for all) or QOL (p>0.19 for all). Conclusion ED patients with low-risk PE reported high satisfaction with their care in follow-up surveys. Expedited discharge (<24 hours) and site of discharge were not associated with differences in patient satisfaction.
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Affiliation(s)
- Laura E Simon
- Kaiser Permanente, Division of Research, Oakland, California
| | - Hilary R Iskin
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Ridhima Vemula
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jie Huang
- Kaiser Permanente, Division of Research, Oakland, California
| | | | - Mary E Reed
- Kaiser Permanente, Division of Research, Oakland, California
| | - Dustin W Ballard
- Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente San Rafael Medical Center, Department of Emergency Medicine, San Rafael, California
| | - David R Vinson
- Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente Sacramento Medical Center, Department of Emergency Medicine, Sacramento, California
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31
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Goldhaber SZ. Cautionary Notes About Outpatient Treatment of Acute Pulmonary Embolism. Chest 2018; 154:233-234. [PMID: 30080496 DOI: 10.1016/j.chest.2018.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 02/07/2018] [Indexed: 01/22/2023] Open
Affiliation(s)
- Samuel Z Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Bledsoe JR, Woller SC, Stevens SM, Aston V, Patten R, Allen T, Horne BD, Dong L, Lloyd J, Snow G, Madsen T, Elliott CG. Management of Low-Risk Pulmonary Embolism Patients Without Hospitalization. Chest 2018; 154:249-256. [DOI: 10.1016/j.chest.2018.01.035] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/17/2018] [Accepted: 01/19/2018] [Indexed: 12/18/2022] Open
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Hepburn-Brown M, Irving L, Hammerschlag G. Early decision-making in acute pulmonary embolism: a retrospective clinical audit. Intern Med J 2018; 49:481-489. [PMID: 30043543 DOI: 10.1111/imj.14042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/19/2018] [Accepted: 07/19/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is increasing evidence supporting early discharge of patients with acute pulmonary embolism (aPE) deemed 'low prognostic risk' as a safe and viable alternative to admission if identified correctly by guideline algorithms. AIM To determine if risk stratification guidelines were followed accurately in an Australian tertiary hospital. METHODS Patients admitted to the emergency department with a diagnosis of PE were included from December 2012 to December 2017. The 272 patients were retrospectively assessed for prognostic risk prior to and after release of the 2014 European Society of Cardiology (ESC) guidelines. This included the simplified Pulmonary Embolism Severity Index (sPESI), and evidence of right heart dysfunction. Thereafter, patients were dichotomised into low (i.e. sPESI = 0) and non-low (i.e. sPESI ≥1 with or without the evidence of right heart dysfunction) prognostic risk groups. RESULTS Prior to ESC guideline release, 52 (65%) of the 80 patients diagnosed with PE were non-low risk and 12 (23%) of these were discharged home; 11 (91.7%) of the 12 discharges had unrecognised sPESI medical history components. After ESC guideline release, 122 (63.5%) of the 192 patients were non-low risk and 20 (16.4%) of these were discharged home; 18 (90%) of the 20 discharges had unrecognised sPESI medical history components. CONCLUSION We found that the sPESI score is not adequately applied in determining prognostic risk for acute PE. In cases of non-low-risk discharge, both prior to and after ESC guideline release, the medical history components of the sPESI score are under-recognised as a marker of increased prognostic risk.
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Affiliation(s)
- Morgan Hepburn-Brown
- Melbourne Medical School, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne Medical School, Melbourne, Victoria, Australia.,Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Louis Irving
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Gary Hammerschlag
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Outpatient Management of Emergency Department Patients With Acute Pulmonary Embolism: Variation, Patient Characteristics, and Outcomes. Ann Emerg Med 2018; 72:62-72.e3. [DOI: 10.1016/j.annemergmed.2017.10.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/12/2017] [Accepted: 10/19/2017] [Indexed: 11/20/2022]
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Howard LSGE, Barden S, Condliffe R, Connolly V, Davies CWH, Donaldson J, Everett B, Free C, Horner D, Hunter L, Kaler J, Nelson-Piercy C, O-Dowd E, Patel R, Preston W, Sheares K, Campbell T. British Thoracic Society Guideline for the initial outpatient management of pulmonary embolism (PE). Thorax 2018; 73:ii1-ii29. [PMID: 29898978 DOI: 10.1136/thoraxjnl-2018-211539] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Luke S G E Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | | | | | | | | | | | - Catherine Free
- Department of Respiratory Medicine, George Eliot Hospital, Nuneaton, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK.,The Royal College of Emergency Medicine, London, UK
| | | | - Jasvinder Kaler
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Emma O-Dowd
- Department of Respiratory Medicine, Nottingham City Hospital, Nottingham, UK
| | - Raj Patel
- King's College Hospital NHS Foundation Trust, London, UK
| | | | - Karen Sheares
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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Liu MY, Ballard DW, Huang J, Rauchwerger AS, Reed ME, Bouvet SC, Vinson DR. Acute Pulmonary Embolism in Emergency Department Patients Despite Therapeutic Anticoagulation. West J Emerg Med 2018; 19:510-516. [PMID: 29760849 PMCID: PMC5942018 DOI: 10.5811/westjem.2018.1.35586] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 12/16/2017] [Accepted: 01/07/2018] [Indexed: 12/03/2022] Open
Abstract
Introduction Emergency department (ED) patients with acute pulmonary embolism (PE) despite therapeutic anticoagulation at the time of diagnosis are uncommonly encountered and present a diagnostic and management challenge. Their characterization and outcomes are poorly described. We sought to describe the prevalence and characteristics of therapeutically anticoagulated patients among a population of patients with acute PE in a community setting and to describe treatment changes and 30-day outcomes. Methods From a large retrospective cohort of adults with acute, objectively-confirmed PE across 21 EDs between 01/2013 and 04/2015, we identified patients who arrived on direct oral or injectable anticoagulants, or warfarin with an initial ED international normalized ratio (INR) value ≥2.0. Patients were excluded from the larger cohort if they had received a diagnosis of venous thromboembolism (VTE) in the prior 30 days. We gathered demographic and clinical variables from electronic health records and structured manual chart review. We report discharge anticoagulation regimens and major 30-day adverse outcomes. Results Among 2,996 PE patients, 36 (1.2%) met study criteria. Mean age was 63 years. Eleven patients (31%) had active cancer and 25 (69%) were high risk on the PE Severity Index (Classes III–V), comparable to the larger cohort (p>0.1). Reasons for pre-arrival anticoagulation were VTE treatment or prevention (n=21), and atrial fibrillation or flutter (n=15). All patients arrived on warfarin and one was also on enoxaparin: 32 had a therapeutic INR (2.0–3.0) and four had a supratherapeutic INR (>3.0). Fifteen patients (42%) had at least one subtherapeutic INR (<2.0) in the 14 days preceding their diagnostic visit. Two patients died during hospitalization. Of the 34 ultimately discharged, 22 underwent a change in anticoagulation drug or dosing, 19 of whom received injectables, either to replace or to supplement warfarin. Four patients also received inferior vena cava filters. Thirty-day outcomes included one major hemorrhage and one additional death. No patients experienced recurrent or worsening VTE. Conclusion We found a low prevalence of therapeutic anticoagulation at the time of acute PE diagnosis. Most patients with breakthrough PE underwent a change in therapy, though management varied widely. Subtherapeutic anticoagulation levels in the preceding weeks were common and support the importance of anticoagulation adherence.
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Affiliation(s)
- Michelle Y Liu
- Kaiser Permanente, Division of Research, Oakland, California
| | - Dustin W Ballard
- Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente, San Rafael Medical Center, Department of Emergency Medicine, San Rafael, California
| | - Jie Huang
- Kaiser Permanente, Division of Research, Oakland, California
| | | | - Mary E Reed
- Kaiser Permanente, Division of Research, Oakland, California
| | - Sean C Bouvet
- Kaiser Permanente, Walnut Creek Medical Center, Department of Emergency Medicine, Walnut Creek, California
| | - David R Vinson
- Kaiser Permanente, Division of Research, Oakland, California.,Kaiser Permanente, Sacramento Medical Center, Department of Emergency Medicine, Sacramento, California
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Howard LS. Non-vitamin K antagonist oral anticoagulants for pulmonary embolism: who, where and for how long? Expert Rev Respir Med 2018. [PMID: 29542359 DOI: 10.1080/17476348.2018.1452614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Acute pulmonary embolism (PE) is a relatively common cardiopulmonary emergency that is a major cause of hospitalization and morbidity and is the primary cause of mortality associated with venous thromboembolism (VTE). During the last decade, one of the biggest changes in the management of PE has been the approval of four non-vitamin K antagonist oral anticoagulants (NOACs; apixaban, dabigatran, edoxaban and rivaroxaban) for the treatment of PE and deep vein thrombosis and secondary prevention of VTE. Areas covered: This article reviews the evolving management of PE in the NOAC era and addresses three fundamental questions: who should receive NOACs over conventional heparin/vitamin K antagonist regimens for the treatment of acute PE; should patients be treated as inpatients or outpatients; and how long should patients be treated to reduce the risk of recurrence? Expert commentary: The management of PE is changing. NOACs provide new anticoagulant treatment options for patients with PE, based on Phase III clinical study results. The consistent efficacy and safety profile of NOACs across many PE patient subgroups, including the elderly, fragile patients, those with active cancer and high-risk (right ventricular dysfunction) patients, suggests NOAC use will increase among these patients.
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Affiliation(s)
- Luke S Howard
- a Imperial College Healthcare NHS Trust , Hammersmith Hospital , London , UK
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Ghazvinian R, Gottsäter A, Elf JL. Efficacy and safety of outpatient treatment with direct oral anticoagulation in pulmonary embolism. J Thromb Thrombolysis 2018; 45:319-324. [PMID: 29305675 PMCID: PMC5818558 DOI: 10.1007/s11239-017-1607-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Anticoagulant treatment of acute pulmonary embolism (PE) has traditionally been hospital-based. The lesser need for monitoring with the increasingly used direct acting oral anticoagulants (DOAC) in comparison to warfarin potentially facilitates outpatient treatment of PE with these drugs. This study aimed to evaluate efficacy and safety of outpatient treatment of PE with DOAC. We extracted data from the Swedish quality registry for patients on oral anticoagulation (AuriculA) for all 245 patients in the southernmost hospital region in Sweden (1.3 million inhabitants) selected for outpatient treatment with of PE with DOAC during 2013-2015. Comorbidites, risk factors, and simplified pulmonary embolism severity index were evaluated at baseline, and death, recurrent venous thromboembolism (VTE), and bleeding was recorded during 6 months of follow-up. Outpatient treatment was defined as discharge from the emergency department within 24 h. During 6 months of follow-up, one patient died during DOAC therapy, the cause of death was unrelated to VTE. No VTE recurrences occured, whereas, one patient experienced major bleeding, and five patients experienced minor bleedings. Outpatient treatment of PE with DOAC is efficient and safe in selected patients.
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Affiliation(s)
- R. Ghazvinian
- Division of Vascular Medicine, Skåne University Hospital, Ruth Lundskogs Gata 10, 205 02 Malmö, Sweden
| | - A. Gottsäter
- Division of Vascular Medicine, Skåne University Hospital, Ruth Lundskogs Gata 10, 205 02 Malmö, Sweden
| | - J. L. Elf
- Division of Vascular Medicine, Skåne University Hospital, Ruth Lundskogs Gata 10, 205 02 Malmö, Sweden
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Coombs M, Fox B. Outpatient Treatment of Pulmonary Embolism: a Practical Guide. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2017. [DOI: 10.1007/s40138-017-0144-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Crobach MJT, Dolsma A, Donker ML, Eijsvogel M, Faber LM, Hofstee HMA, Kaasjager KAH, Kruip MJHA, Labots G, Melissant CF, Sikkens MSG, Huisman MV, Zondag W, den Exter PL. Comparison of two methods for selection of out of hospital treatment in patients with acute pulmonary embolism. Thromb Haemost 2017; 109:47-52. [DOI: 10.1160/th12-07-0466] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 10/08/2012] [Indexed: 11/05/2022]
Abstract
SummaryThe aim of this study is to compare the performance of two clinical decision rules to select patients with acute pulmonary embolism (PE) for outpatient treatment: the Hestia criteria and the simplified Pulmonary Embolism Severity Index (sPESI). From 2008 to 2010, 468 patients with PE were triaged with the Hestia criteria for outpatient treatment: 247 PE patients were treated at home and 221 were treated as inpatients. The outcome of interest was all-cause 30-day mortality. In a post-hoc fashion, the sPESI items were scored and patients were classified according to the sPESI in low and high risk groups. Of the 247 patients treated at home, 189 (77%) patients were classified as low risk according to the sPESI and 58 patients (23%) as high risk. In total, 11 patients died during the first month; two patients treated at home and nine patients treated in-hospital. None of the patients treated at home died of fatal PE. Both the Hestia criteria and sPESI selected >50% of patients as low risk, with good sensitivity and negative predictive values for 30-day mortality: 82% and 99% for the Hestia criteria and 91% and 100% for the sPESI, respectively. The Hestia criteria and the sPESI classified different patients eligible for out-patient treatment, with similar low risks for 30-day mortality. This study suggests that the Hestia criteria may identify a proportion of high risk sPESI patiennts who can be safely treated at home, this however requires further validation.
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Klok FA, van der Bijl N, de Roos A, Kroft LJM, Huisman MV, Pasha SM. NT-pro-BNP levels in patients with acute pulmonary embolism are correlated to right but not left ventricular volume and function. Thromb Haemost 2017; 108:367-72. [DOI: 10.1160/th11-12-0901] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 05/09/2012] [Indexed: 11/05/2022]
Abstract
SummaryN-terminal pro-Brain Natriuretic Peptide (NT-pro-BNP) is primarily secreted by left ventricular (LV) stretch and wall tension. Notably, NT-pro-BNP is a prognostic marker in acute pulmonary embolism (PE), which primarily stresses the right ventricle (RV). We sought to evaluate the relative contribution of the RV to NT-pro-BNP levels during PE. A posthoc analysis of an observational prospective outcome study in 113 consecutive patients with computed tomography (CT)-proven PE and 226 patients in whom PE was clinically suspected but ruled out by CT. In all patients RV and LV function was established by assessing ECG-triggered-CT measured ventricular end-diastolic-volumes and ejection fraction (EF). NT-pro-BNP was assessed in all patients. The correlation between RV and LV end-diastolic-volumes and systolic function was evaluated by multiple linear regression corrected for known con-founders. In the PE cohort increased RVEF (β-coefficient (95% confidence interval [CI]) –0.044 (± –0.011); p<0.001) and higher RV enddiastolic-volume (β-coefficient 0.005 (± 0.001); p<0.001) were significantly correlated to NT-pro-BNP, while no correlation was found with LVEF ( β-coefficient 0.005 (± 0.010); p=0.587) and LV end-diastolic-volume (β-coefficient –0.003 (± 0.002); p=0.074). In control patients without PE we found a strong correlation between NT-pro-BNP levels and LVEF ( β-coefficient –0.027 (± –0.006); p<0.001) although not LV enddiastolic-volume (β-coefficient 0.001 (± 0.001); p=0.418). RVEF (β-co-efficient –0.002 (± –0.006); p=0.802) and RV end-diastolic-volume (β-coefficient <0.001 (± 0.001); p=0.730) were not correlated in patients without PE. In PE patients, lower RVEF and higher RV end-diastolic-volume were significantly correlated to NT-pro-BNP levels as compared to control patients without PE. These observations provide patho-physiological ground for the well-known prognostic value of NT-pro-BNP in acute PE.
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den Exter PL, Klok FA, Huisman MV. Reply: N-Terminal Pro–Brain Natriuretic Peptide Trial Design. Am J Respir Crit Care Med 2017; 196:531-532. [DOI: 10.1164/rccm.201701-0252le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Maestre Peiró A, Gonzálvez Gasch A, Monreal Bosch M. Update on the risk stratification of acute symptomatic pulmonary thromboembolism. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2017.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Update on the risk stratification of acute symptomatic pulmonary thromboembolism. Rev Clin Esp 2017; 217:342-350. [PMID: 28476246 DOI: 10.1016/j.rce.2017.02.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 02/22/2017] [Accepted: 02/23/2017] [Indexed: 01/22/2023]
Abstract
Early mortality in patients with pulmonary thromboembolism (PTE) varies from 2% in normotensive patients to 30% in patients with cardiogenic shock. The current risk stratification for symptomatic PTE includes 4 patient groups, and the recommended therapeutic strategies are based on this stratification. Patients who have haemodynamic instability are considered at high risk. Fibrinolytic treatment is recommended for these patients. In normotensive patients, risk stratification helps differentiate between those of low risk, intermediate-low risk and intermediate-high risk. There is currently insufficient evidence on the benefit of intensive monitoring and fibrinolytic treatment in patients with intermediate-high risk. For low-risk patients, standard anticoagulation is indicated. Early discharge with outpatient management may be considered, although its benefit has still not been firmly established.
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Cardiovascular Conditions in the Observation Unit: Beyond Chest Pain. Emerg Med Clin North Am 2017; 35:549-569. [PMID: 28711124 DOI: 10.1016/j.emc.2017.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The first emergency department observation units (EDOUs) focused on chest pain and potential acute coronary syndromes. However, most EDOUs now cover multiple other conditions that lend themselves to protocolized, aggressive diagnostic and therapeutic regimens. In this article, the authors discuss the management of 4 cardiovascular conditions that have been successfully deployed in EDOUs around the country.
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Roy PM, Moumneh T, Penaloza A, Sanchez O. Outpatient management of pulmonary embolism. Thromb Res 2017; 155:92-100. [DOI: 10.1016/j.thromres.2017.05.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/21/2017] [Accepted: 05/01/2017] [Indexed: 01/17/2023]
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A new prognostic strategy for adult patients with acute pulmonary embolism eligible for outpatient therapy. J Thromb Thrombolysis 2017; 43:326-332. [PMID: 27822904 DOI: 10.1007/s11239-016-1451-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We sought to derive a parsimonious predictive model to identify a subgroup of patients that will experience a low number of adverse events within 14 days of the diagnosis of pulmonary embolism. Retrospective cohort study of adult patients with acute pulmonary embolism at the Ottawa Hospital between 2007 and 2012. Primary outcome was defined as the composite of all-cause mortality, recurrent venous thromboembolism and major bleeding within 14 days. Multivariate logistic regression models were fit to model the occurrence of the primary outcome so as to guide either outpatient therapy or early discharge after initial admission. Calibration and discrimination were assessed in both the derivation and internal validation cohorts. 1143 patients were included, of whom 42% were treated as outpatients. At pulmonary embolism diagnosis, final score to predict the primary outcome included age, malignancy, intravenous drug or oxygen requirement and systolic blood pressure <90 mmHg, with an area under the curve (AUC) of 0.79 (95% CI 0.73-0.84) and 0.82 (95% CI 0.75-0.89) in the derivation and validation cohorts respectively. Conversely, final score to predict primary outcome after initial admission included age, malignancy, intravenous drug requirement and systolic blood pressure <90 mmHg (AUC: 0.70 (95% CI 0.64-0.76) and 0.72 (95% CI 0.66-0.79) in the derivation and validation cohorts). We have developed two simple clinical scores that may identify patients with pulmonary embolism at low risk of clinically meaningful outcomes during the first 14 days of follow up.
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Dubie E, Pouzet G, Bohyn E, Meunier C, Wuyts A, Chateigner Coelsch S, Lesage P, Morvan C, Belle L, Vanzetto G. [Outpatient management of pulmonary embolism diagnosed in emergency services]. Ann Cardiol Angeiol (Paris) 2016; 65:322-325. [PMID: 27693164 DOI: 10.1016/j.ancard.2016.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 09/02/2016] [Indexed: 10/20/2022]
Abstract
In the emergency department, the management of patients with pulmonary embolism depends on the early mortality risk. Outpatient care is possible in low-risk patients. We present the existing scores and the strategy proposed by the North Alps Emergency Network, which uses the simplified PESI score (Pulmonary Embolism Severity Index) to select those low-risk patients, candidates for early discharge.
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Affiliation(s)
- E Dubie
- Centre hospitalier métropole Savoie, Medical Emergency Service, BP 31125, 7, square Massalaz, 73011 Chambéry cedex, France.
| | - G Pouzet
- Centre hospitalier métropole Savoie, Medical Emergency Service, BP 31125, 7, square Massalaz, 73011 Chambéry cedex, France
| | - E Bohyn
- Centre hospitalier Annecy-Genevois, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - C Meunier
- Centre hospitalier de Saint-Jean-de-Maurienne, rue du Dr-Grange, 73300 Saint-Jean-de-Maurienne, France
| | - A Wuyts
- Centre hospitalier d'Albertville-Moutiers, 253, rue Pierre-de-Coubertin, 73200 Albertville, France
| | - S Chateigner Coelsch
- Centre hospitalier de Bourg-Saint-Maurice, 139, rue du Nantet, 73700 Bourg-Saint-Maurice, France
| | - P Lesage
- Centre hospitalier métropole Savoie, Medical Emergency Service, BP 31125, 7, square Massalaz, 73011 Chambéry cedex, France
| | - C Morvan
- Réseau Nord-Alpin des urgences, centre hospitalier Annecy-Genevois, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - L Belle
- Réseau Nord-Alpin des urgences, centre hospitalier Annecy-Genevois, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - G Vanzetto
- Centre hospitalier universitaire Grenoble-Alpes, boulevard de la Chantourne, 38700 la Tronche, France
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Stein PD, Matta F, Hughes MJ. National Trends in Home Treatment of Acute Pulmonary Embolism. Clin Appl Thromb Hemost 2016; 24:115-121. [PMID: 27789604 DOI: 10.1177/1076029616674827] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Management of patients with acute pulmonary embolism has evolved from obligatory hospitalization to home treatment of carefully selected low-risk patients. The purpose of this investigation is to determine national trends in the prevalence of home treatment of pulmonary embolism. METHODS The Nationwide Emergency Department Sample was used to determine the number of patients seen in emergency departments throughout the United States with a primary (first-listed) diagnosis of pulmonary embolism and the proportion hospitalized according to age, from 2007 to 2012. The National (Nationwide) Inpatient Sample was used to determine in-hospital all-cause mortality and length of stay of hospitalized patients. Patients were adults (≥18 years) of both genders and all races from all regions of the United States. Excluded patients were those in shock or on ventilator support. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients and comorbid conditions. RESULTS Home treatment was selected for 54 494 (6.0%) of 915 702 stable patients with acute pulmonary embolism. The proportion of patients treated at home was age-dependent, highest in those aged 30 years or younger, 12.1%, and lowest in those >80 years, 2.9%. Most patients treated at home, 66.8%, and had no comorbid conditions. In-hospital all-cause deaths were 2.6%. Deaths were ≤0.9% in those ≤40 years and 4.8% in those >80 years. Length of stay was 6 days or longer in 37.6% of patients. CONCLUSION In view of the lower death rate among younger patients, they might be a group in whom home treatment would be more advantageous than in elderly patients.
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Affiliation(s)
- Paul D Stein
- 1 Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Fadi Matta
- 1 Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Mary J Hughes
- 1 Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
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den Exter PL, Zondag W, Klok FA, Brouwer RE, Dolsma J, Eijsvogel M, Faber LM, van Gerwen M, Grootenboers MJ, Heller-Baan R, Hovens MM, Jonkers GJPM, van Kralingen KW, Melissant CF, Peltenburg H, Post JP, van de Ree MA, Vlasveld LT(T, de Vreede MJ, Huisman MV. Efficacy and Safety of Outpatient Treatment Based on the Hestia Clinical Decision Rule with or without N-Terminal Pro–Brain Natriuretic Peptide Testing in Patients with Acute Pulmonary Embolism. A Randomized Clinical Trial. Am J Respir Crit Care Med 2016; 194:998-1006. [DOI: 10.1164/rccm.201512-2494oc] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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